Report Signs and Symptoms, Not Unconfirmed Diagnoses

In the outpatient setting, do not code a diagnosis unless it is certain. Examples of language seen in the medical record that identify uncertain diagnoses include:

• Probable
• Suspected
• Questionable
• Rule out
• Differential
• Working

When a definitive diagnosis has not been determined, code the signs, symptoms, and abnormal test result(s) or other reasons for the visit.

In the inpatient setting for facility diagnosis coding, it is appropriate to report suspected or rule out diagnoses as if the condition does exist. This is only true for facility reporting for inpatient services, for all diagnoses except HIV. HIV is the only condition that must be confirmed if it is to be reported in the inpatient setting.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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